広汎性子宮全摘術における膀胱子宮靭帯前・後層の安全かつ確実な処理法について(<特集>第56回日本産科婦人科学会シンポジウム4 : 安全性および確実性の向上を目指した婦人科手術の工夫)

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  • 高倉,賢二
    京都大学大学院医学研究科器官外科学・婦人科学産科学

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  • A Safe and Secure Modification for Dissection of Anterior and Posterior Leaves of Vesico-uterine Ligaments in Okabayashi's Radical Hysterectomy

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In Japan, radical hysterectomy for invasive cervical cancer was established by prof. Okabayashi in our department in 1921. Since then several modifications have been made to the Okabayashi's operation. Nowadays each parametrial vessel was isolated, cut, and ligated to preserve the parasympathetic nervous tissue and to avoid inadvertent massive hemorrhage. In Okabayashi's operation, inadvertent massive hemorrhage is most possible in two steps of the operation, both of which included blinded procedures. One is the dissection of the cardinal ligament, and the other one is the dissection of anterior and posterior leaves of the vesico-uterine ligament. Although the cardinal ligament is safely dissected by isolating each parametrial vessel now, the procedure of vesico-uterine ligament dissection has remained unchanged from the original Okabayashi's operation. To reduce blood loss during radical hysterectomy, it is indispensable to make a safe and secure modification of the vesicouterine ligament dissection, but the precise anatomy of blood vessels in the ligament has been unknown. The aim of this study is to develop a safe and secure procedure of the vesico-uterine ligament dissection based on the precise anatomy of the vesico-uterine ligament, especially blood vessels included inside. Women with operative invasive cervical cancer were eligible. During radical hysterectomy (Okabayashi's method) , individual blood vessels in the vesico-uterine ligament are meticulously identified and isolated under magnification (× 2.5) with the surgical loupe and the surgical headlight. Hemostasis was ensured by monopolar electrocoagulation and bipolar scissors. The anterior leaf of the vesico-uterine ligament is separated from the cervix and the ureter is identified. The superior vesical vein is identified on the surface of the anterior leaf, running from the urinary bladder to the superficial uterine vein. After isolation, cutting and ligation of the vein, the uterine artery of the uterine side becomes well mobilized and is displaced medially. In the connective tissues of the ureteral tunnel, a pair of small blood vessels (cervico-vesical vessels) that run over the ureter from the lateral cervix to the urinary bladder are isolated, cut and ligated. The ureter is freed from its attachment to the posterior leaf of the vesico-uterine ligament. The nerve bundles and the middle vesical vein in the posterior leaf are doubly clamped and divided. In addition, we often observed a vein (inferior vesical vein) that runs parallel to the cervix from the posterior portion of the urinary bladder, which also drains into the deep uterine vein. After cutting and ligating these veins, the urinary bladder with ureter is completely separated from the lateral cervix and the upper vagina. Blood loss during the separation of the vesico-uterine ligament and after radical hysterectomy is measured. The postoperative bladder function is also evaluated. Forty-three cases(pT1b : 26, pT2a : 5, pT2b : 6, pT3a : 1, after transarterial anticancer-drug infusion : 5) underwent the modified procedure. Twenty-seven cases of the conventional method (pT1b : 15, pT2a : 2, pT2b : 4, pT3b : 1, after transarterial anticancer-drug infusion : 5) were served as controls. The blood loss during the separation of the vesico-uterine ligament was less than 10-30g and the mean total blood loss after radical hysterectomy was 181g (50g-360g). The mean blood loss during the conventional method was 296g. Homologous blood transfusion was unnecessary in all cases in the modified method, and was performed in 3 cases (11.1%) in the conventional method. Residual urine volume after operation was decreased significantly earlier in the modified group than in the conventional group. Blood loss during radical hysterectomy can be reduced by our modification of Okabayashi's operation based on the precise anatomy of the blood vessels in the vesico-uterine liga ment.

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